OBJECTIVES : The American College of Gastroenterology (ACG) recently released guidelines for the management of acute severe ulcerative colitis (ASUC) that recommend infliximab, cyclosporine, or surgical intervention (colectomy) as primary treatment options. While the cost-effectiveness of induction and maintenance therapy for UC has been investigated in many studies, there is limited information for ASUC. We evaluated the cost-effectiveness of pharmacologic treatments compared to surgery for patients hospitalized due to ASUC.

METHODS : A Markov model was developed from a US payer perspective with a one-week cycle length over a one-year time horizon. Interventions included infliximab, infliximab biosimilars (infliximab-abda and infliximab-dyyb), and cyclosporine compared to surgery. Patients treated with pharmacologic treatments could transition to remission, response without remission, or surgery. Health state utilities were included for active UC, response without remission, remission, post-surgical remission, and post-surgical complications. Costs included drug wholesale acquisition cost, administration, inpatient stay for ASUC, surgery, post-surgical complications, and endoscopy. We calculated incremental cost per quality-adjusted life year (QALY) gained, cost per life year (LY) in remission, and cost per surgery avoided.

RESULTS : All pharmacologic treatments were more costly than surgery (infliximab: $61,602; infliximab-abda: $48,259; infliximab-dyyb: $52,970; cyclosporine: $4,293; surgery: $38,411) with greater QALYs (infliximab: 0.7825; infliximab-abda: 0.7825; infliximab-dyyb: 0.7825; cyclosporine: 0.7466; surgery: 0.723) Cyclosporine was the most cost-effective at $61,415/QALY, followed by infliximab-abda ($122,860/QALY), infliximab-dyyb ($181,630), and infliximab ($289,312). Pharmacologic treatments were dominated by surgery for the outcome of cost per LY in remission. Cost per surgery avoided ranged from $7,901 for cyclosporine to $41,259 for infliximab.

CONCLUSIONS : Cyclosporine and infliximab biosimilars may present cost-effective treatment options compared to elective colectomy for patients hospitalized ASUC from the payer perspective over a 1-year time horizon. Results are limited by the lack of rigorous controlled studies in hospitalized ASUC and uncertainty in the long-term maintenance of response to pharmacologic treatments.